Provider Demographics
NPI:1548986326
Name:SMITH, BRENDAN SCOTT (DMD)
Entity type:Individual
Prefix:
First Name:BRENDAN
Middle Name:SCOTT
Last Name:SMITH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3814 DULANEY PL
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-0815
Mailing Address - Country:US
Mailing Address - Phone:217-779-8871
Mailing Address - Fax:
Practice Address - Street 1:124 N 12TH ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-3021
Practice Address - Country:US
Practice Address - Phone:217-222-5058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019033809122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty